Postoperative malrotation of humeral shaft fracture after plating compared with intramedullary nailing

Management of Humeral Shaft Fracture: A Network Meta-Analysis of Individual Treatment Modalities

OBJECTIVE

The purpose of this study was to perform a network meta-analysis of level I and II evidence comparing different management techniques to define the optimum treatment method for humeral shaft fractures (HSFs).

METHODS

DATA SOURCES

A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines of MEDLINE, Embase, and Cochrane Library was screened from 2010 to 2023.

STUDY SELECTION

Inclusion criteria were evidence level I or II studies comparing nonoperative and/or operative repair techniques including open reduction internal fixation plate osteosynthesis (ORIF-Plate), minimally invasive percutaneous plating (MIPO), and intramedullary nail (IMN) fixation for the management of HSFs (OTA/AO 12A, B, C).

DATA EXTRACTION

The risk of bias and methodologic quality of evidence were assessed according to the guidelines designed by the Cochrane Statistical Methods Group and Cochrane Methods Bias Group.

DATA SYNTHESIS

Network meta-analysis was conducted with a frequentist approach with a random-effects model using the netmeta package version 0.9-6 in R.

RESULTS

A total of 25 studies (1908 patients) were included. MIPO resulted in the lowest complication rate (2.1%) when compared with ORIF-Plate (16.1%) [odds ratio (OR), 0.13; 95% confidence interval (CI), 0.04-0.49]. MIPO resulted in the lowest nonunion rate (0.65%) compared with all management techniques (OR, 0.28; 95% CI, 0.08-0.98), whereas Non-Op resulted in the highest (15.87%) (OR, 3.48; 95% CI, 1.98-6.11). MIPO demonstrated the lowest rate of postoperative radial nerve palsy overall (2.2%) and demonstrated a significantly lower rate compared with ORIF-Plate (OR, 0.22; 95% CI, 0.07-0.71, P = 0.02). IMN resulted in the lowest rate of deep infection (1.1%) when compared with ORIF-Plate (8.6%; P = 0.013). MIPO resulted in a significantly lower Disabilities of the Arm, Shoulder, and Hand score (3.86 ± 5.2) and higher American Shoulder and Elbow Surgeons score (98.2 ± 1.4) than ORIF-Plate (19.5 ± 9.0 and 60.0 ± 5.4, P < 0.05).

CONCLUSION

The results from this study support that surgical management results in better postoperative functional outcomes, leads to higher union rates, reduces fracture healing time, reduces revision rate, and decreases malunion rates in patients with HSFs. In addition, MIPO resulted in statistically higher union rates, lowest complication rate, lowest rate of postoperative radial nerve palsy, and lower intraoperative time while resulting in better postoperative Disabilities of the Arm, Shoulder, and Hand and American Shoulder and Elbow Surgeons scores when compared with nonoperative and operative (ORIF and IMN) treatment modalities.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Intramedullary nailing vs. open reduction-internal fixation for humeral shaft fractures: a meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this study was to perform a meta-analysis of randomized controlled trials (RCTs) to compare outcomes following intramedullary nailing (IMN) vs. open reduction-internal fixation (ORIF) for humeral shaft fractures.

METHODS

A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RCTs comparing IMN and ORIF for humeral shaft fractures were included. Clinical outcomes were compared using RevMan. P < .05 was considered statistically significant.

RESULTS

Ten RCTs with 512 patients were included. Overall, 8.4% of patients treated with IMN and 6.4% of patients treated with ORIF had nonunion (P = .57, I2 = 0%), with a significantly faster time to union with IMN (10 weeks vs. 11.9 weeks, P < .05). There was no significant difference in the rate of reoperation (11.6% in IMN group vs. 7.6% in ORIF group, P = .26) or radial nerve palsy (2.8% in IMN group vs. 4.2% in ORIF group, P = .58). A lower rate of infection was noted with IMN (1.2% vs. 5.3%, P < .05). Additionally, there was a lower operative time with IMN (61 minutes vs. 88 minutes, P < .05).

CONCLUSIONS

The Level I evidence in the literature does not show a significant difference in rates of union, reoperation, or radial nerve palsy between IMN and ORIF for humeral shaft fractures. Overall, treatment with IMN results in a lower infection rate, less operative time, and a modestly quicker time to union. The optimal treatment strategy for humeral shaft fractures may be best informed by fracture pattern and surgeon preference.

Shoulder problems after percutaneous antegrade intramedullary nailing in humeral diaphyseal fractures using contemporary straight third-generation nail

BACKGROUND

Antegrade intramedullary nailing in humeral shaft fracture has been abandoned by certain orthopedic surgeons because of rotator cuff injury caused by first- and second-generation intramedullary nails (IMNs). However, only a few studies have specifically addressed the results of antegrade nailing for the treatment of humeral shaft fractures with a straight third-generation IMN; thus, complications need to be re-evaluated. We hypothesized that fixation of displaced humeral shaft fractures with a straight third-generation antegrade IMN with the percutaneous technique avoid shoulder problems (stiffness and pain) incurred by first- and second-generation IMNs.

METHODS

This was a retrospective, single-center, nonrandomized study of 110 patients with a displaced humeral shaft fracture between 2012 and 2019 treated surgically with a long third-generation straight IMN. Mean follow-up was 35.6 months (range, 15-44 months).

RESULTS

There were 73 women and 37 men with a mean age of 64.7 ± 19 years. All fractures were closed (37.3% 12A1, 13.6% 12B2, and 13.6% 12B3 AO/OTA classification). Mean Constant score was 82 ± 19, Mayo Elbow Performance Score 96 ± 11 and the mean EQ-5D visual analog scale score was 69.7 ± 21.5. Mean forward elevation 150° ± 40°, abduction 148° ± 45°, and external rotation 38° ± 15°. Symptoms associated with rotator cuff disease were present in 6.4%. Evidence of radiographic fracture healing was detected in all but 1 case. One postoperative nerve injury and 1 adhesive capsulitis were present. Overall, 6.3% underwent second surgeries (4.5% were minor surgeries like hardware removal).

CONCLUSION

Percutaneous antegrade intramedullary nailing of humeral shaft fractures with a straight third-generation nail considerably reduced complications related to shoulder problems and achieved good functional results.

[Therapy of Humeral Shaft Fractures]

Humeral shaft fractures are a rare but challenging entity of injuries of the upper extremity. Despite all advances in the past decades - including improved imaging, adjusted surgical techniques and new implant designs - the treatment of humeral shaft fractures and especially the treatment choice remains challenging. Treatment options need to be evaluated individually under consideration of fracture morphology, soft tissue and potential neurological damage as well as patient-specific factors (i.e., age, comorbidities). Moreover, the risk of common complications such as radial nerve palsy, infection, non-union and malrotation needs to be evaluated in order to facilitate the best possible therapy for each patient. The regular available treatment options include conservative (cast, brace, etc.) and surgical measures (ante- and retrograde nailing, angle-stable plate osteosynthesis). Furthermore, (temporary) external fixation remains an option in emergency and complicative cases. However, none of the aforementioned options have proven a superior gold standard. This review evaluates the currently available treatment options and their individual advantages as well as the probability of possible complications and is aiming to supply a guide for individual treatment choice.

Conservative Management with Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis

BACKGROUND

Historically, humeral shaft fractures have been successfully treated with nonoperative management and functional bracing; however, various surgical options are also available. In the present study, we compared the outcomes of nonoperative versus operative interventions for the treatment of extra-articular humeral shaft fractures.

METHODS

This study was a network meta-analysis of prospective randomized controlled trials (RCTs) in which functional bracing was compared with surgical techniques (including open reduction and internal fixation [ORIF], minimally invasive plate osteosynthesis [MIPO], and intramedullary nailing in both antegrade [aIMN] and retrograde [rIMN] directions) for the treatment of humeral shaft fractures. The outcomes that were assessed included time to union and the rates of nonunion, malunion, delayed union, secondary surgical intervention, iatrogenic radial nerve palsy, and infection. Mean differences and log odds ratios (ORs) were used to analyze continuous and categorical data, respectively.

RESULTS

Twenty-one RCTs evaluating the outcomes for 1,203 patients who had been treated with functional bracing (n = 190), ORIF (n = 479), MIPO (n = 177), aIMN (n = 312), or rIMN (n = 45) were included. Functional bracing yielded significantly higher odds of nonunion and significantly longer time to union than ORIF, MIPO, and aIMN (p < 0.05). Comparison of surgical fixation techniques demonstrated significantly faster time to union with MIPO than with ORIF (p = 0.043). Significantly higher odds of malunion were observed with functional bracing than with ORIF (p = 0.047). Significantly higher odds of delayed union were observed with aIMN than with ORIF (p = 0.036). Significantly higher odds of secondary surgical intervention were observed with functional bracing than with ORIF (p = 0.001), MIPO (p = 0.007), and aIMN (p = 0.004). However, ORIF was associated with significantly higher odds of iatrogenic radial nerve injury and superficial infection than both functional bracing and MIPO (p < 0.05).

CONCLUSIONS

Compared with functional bracing, most operative interventions demonstrated lower rates of reoperation. MIPO demonstrated significantly faster time to union while limiting periosteal stripping, whereas ORIF was associated with significantly higher rates of radial nerve palsy. Nonoperative management with functional bracing demonstrated higher nonunion rates than most surgical techniques, often requiring conversion to surgical fixation.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Functional and Clinical Outcomes After Plate Osteosynthesis Versus Intramedullary Nailing of a Humeral Shaft Fracture: The Results of the HUMMER Multicenter, Prospective Cohort Study

BACKGROUND

Plate osteosynthesis (referred to throughout as plating) and intramedullary nailing (referred to throughout as nailing) are the most common operative strategies for humeral shaft fractures. However, it is undecided which treatment is more effective. This study aimed to compare functional and clinical outcomes of these treatment strategies. We hypothesized that plating would result in an earlier recovery of shoulder function and fewer complications.

METHODS

From October 23, 2012, to October 3, 2018, adults with a humeral shaft fracture, OTA/AO type 12A or 12B, were enrolled in a multicenter, prospective cohort study. Patients were treated with plating or nailing. Outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) score, Constant-Murley score, ranges of motion of the shoulder and elbow, radiographic healing, and complications until 1 year. Repeated-measure analysis was done with correction for age, sex, and fracture type.

RESULTS

Of the 245 included patients, 76 were treated with plating and 169 were treated with nailing. Patients in the plating group were younger, with a median age of 43 years compared with 57 years for the nailing group (p < 0.001). The mean DASH score after plating improved faster over time, but did not differ significantly from the score after nailing at 12 months (11.7 points [95% confidence interval (CI), 7.6 to 15.7 points]) for plating and 11.2 points [95% CI, 8.3 to 14.0 points] for nailing). The Constant-Murley score and shoulder abduction, flexion, external rotation, and internal rotation displayed a significant treatment effect (p treatment ≤ 0.001), in favor of plating. The plating group had 2 implant-related complications, whereas the nailing group had 24, including 13 nail protrusions and 8 screw protrusions. Plating resulted in more postoperative temporary radial nerve palsy (8 patients [10.5%] compared with 1 patient [0.6%]; p < 0.001) and a trend toward fewer nonunions (3 patients [5.7%] compared with 16 patients [11.9%]; p = 0.285) than nailing.

CONCLUSIONS

Plating of a humeral shaft fracture in adults results in faster recovery, especially of shoulder function. Plating was associated with more temporary nerve palsies, but fewer implant-related complications and surgical reinterventions, than nailing. Despite heterogeneity in implants and surgical approach, plating seems to be the preferred treatment option for these fractures.

LEVEL OF EVIDENCE

Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.

Treatment of humeral shaft fractures with different treatment methods: a network meta-analysis of randomized controlled trials

PURPOSE

Humeral shaft fractures (HSFs) can be treated non-operatively (Non-OP), with open reduction and plate osteosynthesis (ORPO), minimally invasive plate osteosynthesis (MIPO), or with intramedullary nails (IMN). However, the best treatment for HSFs still remains controversial.We performed a network meta-analysis to explore which should be the best method for HSFs.

METHODS

The computerized search had been conducted on electronic databases PubMed, EMBASE, Cochrane Library, and Medline from the establishment of the database to the end of December 2022. The quality evaluation of the included literature had been completed by Review Manager (version 5.4.1). Stata 17.0 software (Stata Corporation, College Station, Texas, USA)was used for network meta-analysis.We included randomized controlled trials (RCTs) comparing different treatments to treating HSFs.

RESULTS

The pairwise comparison results demonstrated that there was no statistical difference between IMN, MIPO, Non-OP, and ORPO in terms of radial nerve injury and infection, and Non-OP presented significantly more nonunion than ORPO, IMN, and MIPO. However, no statistically significant difference between ORPO, IMN, and MIPO was discovered. The results of the network meta-analysis displayed that surface under the cumulative ranking curve (SUCRA) probabilities of IMN, MIPO, Non-OP, and ORPO in radial nerve injury were 46.5%, 66.9%, 77.3%, and 9.3%, respectively, in contrast, that in infection were 68.6%, 53.3%, 62.4%, and 15.4%, respectively, and that in nonunion were 51.7%, 93.1%, 0.7%, and 54.5%, respectively.

CONCLUSION

We came to the conclusion that MIPO is currently the most effective way to treat HSFs.

TRIAL REGISTRATION

Name of the registry: Prospero, 2. Unique Identifying number or registration ID: CRD42023411293.

Evaluation of Humeral Shaft Fracture Outcomes by Treatment Method: A Systematic Review and Meta-analysis Based on Comparison Studies

BACKGROUND

The purpose of this systematic review and meta-analysis was to evaluate various outcomes of humeral shaft fractures treated with different treatment methods, which included functional bracing, open reduction and internal fixation, intramedullary nailing, and locked compression plate.

METHODS

A systematic review was performed using research databases including PubMed, EMBASE, and Google Scholar. Keywords relating to treatment of humeral shaft fractures were used, and comparison studies that reported patient characteristics and outcomes, including nonunion, malunion, function scores, and complications, were included. One hundred fourteen records were screened, with 18 studies ultimately included in the meta-analysis. Treatment groups were consolidated into brace or surgery and then further categorized into subgroups based on surgical technique used. Postoperative events, complications, and functional scores were compared among the treatment groups. Statistical analysis for this study was conducted using Review Manager 5.3, with a standard p-value of ≤0.05 for statistical significance.

RESULTS

Eighteen studies were included in this review with a total of 706 patients. Z-tests showed that risks of revision, nonunion, and malunion were higher in the brace treatment group compared with the surgical treatment group (p < 0.0001, <0.0001, 0.004, respectively). Risk of infection was expectedly higher in the surgical group compared with the brace group (p = 0.04). Radial nerve injury rates were also higher in the unspecified surgical group compared with the brace group (p = 0.01). In the surgical group, the mean Constant shoulder score was also significantly higher than that in the brace group (p = 0.004). When comparing the nail and plate groups, Z-tests revealed higher risks of delayed unions and other complications in the nail group (p = 0.04 and 0.001, respectively) but higher risk of infection in the plate group (p = 0.05).

CONCLUSION

The conservative treatment of humeral shaft fractures with functional braces may be associated with a lower incidence of infection and nerve injury when compared with operative treatment methods. However, nonoperative treatment may also come with higher risks of revision, nonunion, and malunion than the many available surgical modalities. Operative management with either intramedullary nail or plate has shown to be a reliable method of management with reasonable outcomes for humeral shaft fractures. While the nail group had higher risk of delayed unions and other complications, the plate group had higher risk of infections. Both nail and plate surgical treatments have shown to result in high union rates and should be considered by the surgeon on a case-by-case basis when treating humeral shaft fractures.

LEVEL OF EVIDENCE

Level I. See Instructions for Authors for a complete description of levels of evidence.

Assessment of Intraoperative Rotational Alignment of Closed Locked Intramedullary Nailing for Humerus Fractures

Intramedullary nailing of humerus fractures has evolved over the past half century and has grown in popularity especially for the polytraumatized patient. The importance of restoring appropriate rotational alignment is equivalent to that of restoring sagittal and coronal alignment to decrease the risk of shoulder degenerative changes and limit range of motion discrepancy from the contralateral limb. This technique is designed to introduce an intraoperative fluoroscopic method to obtain adequate rotational alignment of humeral shaft fractures treated with closed antegrade humeral locked nailing.

Radiographic rotational profiles of the proximal and distal humerus: analysis of 46 computed tomography scans with 3-dimensional simulation

BACKGROUND

To date, no study has investigated the radiographic rotational profiles (RRPs) of the proximal and distal humerus. However, malrotation after minimally invasive surgery for humeral fracture has been an unsolved problem. Therefore, we aimed to investigate the RRPs of the proximal and distal humerus that linearly correlate with rotational status and show significant differences as the rotational status changes.

METHODS

Forty-six computed tomography scans of the humerus were 3-dimensionally reconstructed, and 5 rotational statuses (20° and 10° of internal rotation; neutral; and 10° and 20° of external rotation) were simulated. Seven candidate RRPs of the proximal humerus and 4 candidates of the distal humerus were measured for each rotational status. The overall differences and trends in the RRPs as the rotational status changed were evaluated, and multiple comparisons were performed between the RRPs for each of the 5 rotational statuses. Moreover, the correlations between the RRPs and rotational status with adjustment of retroversion were analyzed. Finally, interobserver and intraobserver reliabilities were evaluated.

RESULTS

The following proximal and distal RRPs were linearly correlated with rotational status, differed significantly between the rotational statuses, and showed a relatively low prediction error and excellent interobserver and intraobserver reliabilities: the distance from the tip of the lesser tuberosity to the lateral margin of the proximal humerus (P_L1) and the medial margin of the head (P_L2), as well as the P_L1 to P_L2 ratio (PR_L), in the proximal humerus; and the distance from the medial margin of the olecranon process to the medial epicondyle (D_OP), the widest width of the overlapped olecranon fossa (D_OF), and the distance from the lateral margin of the capitellum to the lateral epicondyle (D_C) in the distal humerus.

CONCLUSION

Our findings suggest that P_L1, P_L2, and PR_L in the proximal humerus and D_OP, D_OF, and D_C in the distal humerus are potentially useful and reproducible RRPs for restoring the intrinsic rotational alignment in humeral fractures.

Fragility of statistically significant findings from randomized clinical trials of surgical treatment of humeral shaft fractures: A systematic review

BACKGROUND

Despite recent meta-analyses of randomized controlled trials (RCTs), there remains no consensus regarding the preferred surgical treatment for humeral shaft fractures. The fragility index (FI) is an emerging tool used to evaluate the robustness of RCTs by quantifying the number of participants in a study group that would need to switch outcomes in order to reverse the study conclusions.

AIM

To investigate the fragility index of randomized control trials assessing outcomes of operative fixation in proximal humerus fractures.

METHODS

We completed a systematic review of RCTs evaluating the surgical treatment of humeral shaft fractures. Inclusion criteria included: articles published in English; patients randomized and allotted in 1:1 ratio to 2 parallel arms; and dichotomous outcome variables. The FI was calculated for total complications, each complication individually, and secondary surgeries using the Fisher exact test, as previously published.

RESULTS

Fifteen RCTs were included in the analysis comparing open reduction plate osteosynthesis with dynamic compression plate or locking compression plate, intramedullary nail, and minimally invasive plate osteosynthesis. The median FI was 0 for all parameters analyzed. Regarding individual outcomes, the FI was 0 for 81/91 (89%) of outcomes. The FI exceeded the number lost to follow up in only 2/91 (2%) outcomes.

CONCLUSION

The FI shows that data from RCTs regarding operative treatment of humeral shaft fractures are fragile and does not demonstrate superiority of any particular surgical technique.

Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management

BACKGROUND

Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated.

METHODS

A decision tree was constructed describing the management of humeral shaft fractures with open reduction-internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated.

RESULTS

Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model-accounting for both health care and societal costs-the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses.

CONCLUSIONS

Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.

Efficacy and Safety Evaluation of Intramedullary Nail and Locking Compression Plate in the Treatment of Humeral Shaft Fractures: A Systematic Review and Meta-analysis

Objective

The surgical treatment scheme of humeral shaft fracture is still controversial with no consensus reached. This meta-analysis was aimed at comparing the efficacy and safety of intramedullary nail (IMN) and locking compression plate (LCP) in the treatment of humeral shaft fractures.

Methods

PubMed, Medline, Embase, Ovid, Cochrane Library, ISI Web of Science, Clinical Trials, and Chinese databases, including China National Knowledge Infrastructure Project, Wanfang database, and China biomedical abstracts database, were used to search the literature. Review Manager software was employed for statistical analysis and establishing forest and funnel maps. Categorical variables were measured by relative risk (RR), and standardized mean difference (SMD) was used to measure continuous variables. 95% confidence intervals were used for each variable. The modified Jadad scale, Newcastle-Ottawa scale, and Cochrane's bias risk tools were used to evaluate the bias and risk of eligible studies.

Results

A total of 14 studies were included in the analysis with a total of 903 patients with humeral shaft fracture. Significant differences with regard to operation time (Std = -1.18, 95% CI: -2.14, -0.22, Z = 2.41, P = 0.02), blood loss (Std = -2.97, 95% CI: -4.32, -1.63, Z = 4.34, P < 0.001), and postoperative infection rate (RR = 0.32, 95% CI: -0.15, 0.68, Z = 2.98, P = 0.003) were noted between the IMN group and LCP group. In addition, the American Shoulder and Elbow Surgeon (ASES) score (Std = -0.22, 95% CI: -0.44, 0.01, Z = 2.08, P = 0.04) and the rate of shoulder and elbow function limitation (RR = 1.88, 95% CI: 1.06, 3.33, Z = 2.17, P = 0.03) between the 2 groups were also statistically significant. There were no significant differences in the rate of radial nerve injury, nonunion, delayed healing, and secondary operation between the two groups.

Conclusion

IMN is superior than the LCP in terms of the operation time, intraoperative bleeding, and postoperative infection, suggesting its superiority in the humeral shaft fracture fixation. However, IMN is inferior to LCP in ASES score and shoulder elbow function limitation rate, indicating poor early postoperative functional recovery. More studies are required to evaluate and analyze the clinical efficacy between IMN and LCP regarding long-term function after artificial graft removal.

Antegrade intramedullary locking nail in the management of proximal and middle thirds of humeral diaphyseal fractures

PURPOSE

The aim of the study was to evaluate the antegrade intramedullary locking nail osteosynthesis for the treatment of the proximal and middle thirds of humeral shaft fractures.

METHODS

A retrospective study was made on 218 patients diagnosed with humeral diaphysis fractures who undergo surgery with antegrade intramedullary locking nail between January 2017 and December 2021. The clinical follow-up started two days after surgery and continued at one month, three months, six months and one year. The functional recovery evaluation was performed using visual analogue scale (VAS) score, Rating Scale of American Shoulder and Elbow Surgeons Form (ASES), Mayo Elbow Performance Score System (MEPS) and rate of complications.

RESULTS

Low intra-operative blood loss, short operation time, short hospitalisation, early mobilisation of the patient and high union rate imposed intramedullary nailing as a standard procedure for the treatment of proximal and middle thirds of humeral diaphyseal fractures in the past years, and the union rate was 99.5%. VAS score evaluated at one month, three months and six months indicated a very good overall post-operative experience. The ASES and MEPS score were evaluated at six months and one year and showed excellent results. All the patients (except 1 case) were able to return to their previous jobs within six months.

CONCLUSION

Humeral nailing is associated with early return to function of the upper limb, with very good clinical and functional outcomes of the shoulder and elbow. This method could be considered the best surgical option for the management of proximal middle humeral fractures.

A finite element model of the shoulder: application to the changes of biomechanical environment induced by postoperative malrotation of humeral shaft fracture

Objectives

The humerus fracture is one of the most commonly occurring fractures. In this research, we attempted to evaluate and compare the extent of malrotation and biomechanical environment after surgical treatment of humeral shaft fractures.

Methods

A finite element (FE) model of the shoulder was built based on Computed Tomography (CT) data of a patient with a humeral shaft fracture. The muscle group around the shoulder joint was simulated by spring elements. The changes of shoulder stresses under rotation were analyzed. The biomechanics of the normal shoulder and postoperative malrotation of the humeral shaft was analyzed and compared.

Results

During rotations, the maximum stress was centered in the posterosuperior part of the glenoid for the normal shoulder. The von Mises shear stresses were 4.40 MPa and 4.89 MPa at 40° of internal and external rotations, respectively. For internal rotation deformity, the shear contact forces were 7–9 times higher for the shoulder internally rotated 40° than for the normal one. For external rotation deformity, the shear contact forces were about 3–5 times higher for the shoulder with 40° external rotation than the normal one.

Conclusion

Postoperative malrotation of humeral shaft fracture induced the changes of the biomechanical environment of the shoulders. The peak degree of malrotation was correlated with increased stresses of shoulders, which could be paid attention to in humeral shaft fracture treatment. We hoped to provide information about the biomechanical environment of humeral malrotation.

Minimally invasive plate osteosynthesis of the humeral shaft with regard to adjacent anatomical characteristics

The study goal was to evaluate the distances from the radial (RN), the musculocutaneous (MN) and axillary nerves (AN) and the medial neurovascular bundle of the upper arm to a minimally invasive applied plate and to define its relation to the RN during different degrees of malrotation during MIPO. The sample involved ten upper extremities. Application of a PHILOS plate was performed through a Delta-split. Intervals between the AN, MN, RN and the medial vascular bundle were defined at various positions. The humeral shaft was artificially fractured at a height of about the mean of the plate. The distal fragment was brought into 15° and 30° internal (IR) as well as external rotation (ER) and here, the plate’s relation to the RN was evaluated. The medial neurovascular bundle intersected the plate at its distal part in two specimens. Regarding the distances from the RN to the plate during different rotation positions the distances became significantly longer during ER, respectively shorter during IR. The medial neurovascular bundle and the RN were identified as the main structures at risk. Care must be taken during distal screw placement and malrotation exceeding 15° must be avoided during MIPO.

Postoperative malrotation of humerus shaft fracture causes degeneration of rotator cuff and cartilage

We hypothesized that postoperative malrotation of humeral shaft fractures can alter the bio-mechanical environment of the shoulder; thus, rotator cuff and cartilage degeneration could be induced. Therefore, we designed an animal experiment to evaluate the impact of malrotation deformities after minimally invasive surgery for humeral fractures on the rotator cuff and cartilage, which has rarely been described in previous studies. Twenty-four New Zealand white rabbits were randomly divided into the sham control group (A), negative control group (B) and malrotated group (C). A sham operation with surgical exposure alone was performed in group A. Humeral shaft osteotomy was performed in Group B and C. In Group B, the fractures were fixed in situ with plate -screw system. While in Group C, iatrogenic rotational deformity was created after the proximal end of the fracture being internally rotated by 20 degrees and then subsequently fixed. The animals with bone healing were sacrificed for pathological and biochemical examination. In group C, the modified Mankin scale for cartilage pathology evaluation and the modified Movin scale for tendon both showed highest score among groups with statistical significance (P < 0.05); Disordered alignment and proportion of collagen I/III of rotator cuff were confirmed with picrosirius red staining; Transmission electron microscopy also showed ultrastructural tendon damage. Immunohistochemistry showed that both MMP-1 and MMP-13 expression were significantly higher in group C than groups A and B(P < 0.05). Minimally invasive techniques for humerus shaft fracture might be cosmetically advantageous, but the consequent postoperative malrotation could increase the risk of rotator cuff and cartilage degeneration. This conclusion is supported here by primary evidence from animal experiments.

Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies

PURPOSE

This meta-analysis compares open reduction and internal fixation with a plate (ORIF) versus nailing for humeral shaft fractures with regard to union, complications, general quality of life and shoulder/elbow function.

METHODS

PubMed/Medline/Embase/CENTRAL/CINAHL was searched for observational studies and randomised clinical trials (RCT). Effect estimates were pooled across studies using random effects models. Results were presented as weighted odds ratio (OR) or risk difference (RD) with corresponding 95% confidence interval (95% CI). Subgroup analysis was performed stratified for study design (RCTs and observational studies).

RESULTS

Eighteen observational studies (4906 patients) and ten RCT's (525 patients) were included. The pooled effect estimates of observational studies were similar to those obtained from RCT's. More patients treated with nailing required re-intervention (RD 2%; OR 2.0, 95% CI 1.0-3.8) with shoulder impingement being the most predominant indication (17%). Temporary radial nerve palsy secondary to operation occurred less frequently in the nailing group (RD 2%; OR 0.4, 95% CI 0.3-0.6). Notably, all but one of the radial nerve palsies resolved spontaneously in each groups. Nailing leads to a faster time to union (mean difference - 1.9 weeks, 95% CI - 2.9 to - 0.9), lower infection rate (RD 2%; OR 0.5, 95% CI 0.3-0.7) and shorter operation duration (mean difference - 26 min, 95% CI - 37 to - 14). No differences were found regarding non-union, general quality of life, functional shoulder scores, and total upper extremity scores.

CONCLUSION

Nailing carries a lower risk of infection, postoperative radial nerve palsy, has a shorter operation duration and possibly a shorter time to union. Shoulder impingement requiring re-intervention, however, is an inherent disadvantage of nail fixation. Notably, absolute differences are small and almost all patients with radial nerve palsy recovered spontaneously. Satisfactory results can be achieved with both treatment modalities.

Radial nerve palsy associated with closed humeral shaft fractures: a systematic review of 1758 patients

BACKGROUND AND PURPOSE

Humeral shaft fractures are often associated with radial nerve palsy (RNP) (8-16%). The primary aim of this systematic review was to assess the incidence of primary and secondary RNP in closed humeral shaft fractures. The secondary aim was to compare the recovery rate of primary RNP and the incidence of secondary RNP between operative and non-operative treatment.

METHODS

A systematic literature search was performed in 'Trip Database', 'Embase' and 'PubMed' to identify original studies reporting on RNP in closed humeral shaft fractures. The Coleman Methodology Score was used to grade the quality of the studies. The incidence and recovery of RNP, fracture characteristics and treatment characteristics were extracted. Chi-square and Fisher exact tests were used to compare operative versus non-operative treatment.

RESULTS

Forty studies reporting on 1758 patients with closed humeral shaft fractures were included. The incidence of primary RNP was 10%. There was no difference in the recovery rate of primary RNP when comparing operative treatment with radial nerve exploration (98%) versus non-operative treatment (91%) (p = 0.29). The incidence of secondary RNP after operative and non-operative treatment was 4% and 0.4%, respectively (p < 0.01).

INTERPRETATION

One-in-ten patients with a closed humeral shaft fracture has an associated primary RNP, of which > 90% recovers without the need of (re-)intervention. No beneficial effect of early exploration on the recovery of primary RNP could be demonstrated when comparing patients managed non-operatively with those explored early. Patients managed operatively for closed humeral shaft fractures have a higher risk of developing secondary RNP.

LEVEL OF EVIDENCE

Level IV; Systematic Review.

Locking compression plate fixation versus intramedullary nailing of humeral shaft fractures: which one is better? A single-centre prospective randomized study

PURPOSE

To compare the radiological and clinical outcomes of interlocking nail (ILN) and locking plate fixation (LCP) for humeral shaft fractures.

METHODS

A total of 63 patients with displaced humeral shaft fractures between October 2014 and January 2017 were evaluated prospectively. They were divided randomly into two as LCP fixation (group 1) and interlocking nail (ILN) (group 2). Functional outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH), American Shoulder and Elbow Surgeons (ASES), the University of California at Los Angeles (UCLA) shoulder scores, and Short Form-36 (SF-36) questionnaires, and pain was assessed with visual analogue scale (VAS).

RESULTS

After fracture callus was radiologically observed, DASH, ASES, and UCLA scores as well as SF-36 questionnaires and VAS results were noted to have no significant difference between the two groups (p = 0.109, p = 0.082, p = 0.146, p = 0.322, and p = 0.175, respectively). At the last follow-up (post-operative 24 months), the UCLA score was significantly better in group 1 (p = 0.034), whereas VAS result was significantly worse in group 2 (p = 0.017). DASH, ASES scores, and SF-36 questionnaires had no difference (p = 0.193, p = 0.088, p = 0.289). Other parameters revealed no significant differences. Fracture consolidation was observed at a mean of four months in both groups (3 to 7 months in group 1 and 3 to 8 months in group 2) (p = 0.189). Four patients in group 1 and five patients in group 2 underwent surgery for nonunion (p = 0.725). Post-operative radial nerve palsy was seen in one patient in group 2. Two patients in group 1 with superficial infection were treated with antibiotics, and they recovered.

CONCLUSIONS

Regarding our results, the LCP group had significantly better shoulder function than the ILN group, whereas the ILN group had significantly less pain, with similar complication rates. Therefore, both procedures are favourable surgical options for patients with humeral shaft fractures.

Geometrical analysis for assessing torsional alignment of humerus

BACKGROUND

Compared to other types of surgeries, minimally invasive surgeries (MISs) of humeral shaft fractures are associated with less radial nerve injury, less soft tissue injury and higher union rate. However, malrotation often occurs in MISs when closed reduction methods are used. This study aims to define specific palpable landmarks to help surgeons determine the correct torsional angle and reduce the incidence of malrotation.

METHODS

Twenty-eight normal humeral computed tomography scans were retrieved from our image database. One line was drawn through the vertices of the intertubercular sulcus of the humeral head in the coronal view, and another line was drawn through the longest axis between the medial and lateral condyles in the coronal view. The angle between these two lines was measured at least 3 times for each scan.

RESULTS

The profile of the intertubercular sulcus tangent line of the humeral head and the axis of the distal humerus was identified as the most accurate method for assessing the precision of torsion during MIS for humeral shaft fractures. The transepicondylar axis line is more internally rotated than the intertubercular sulcus tangent line. The mean angle was measured to be 41.1 degrees.

CONCLUSIONS

The axis of the distal humeral condyles is internally rotated by approximately 41.1 degrees compared with the intertubercular sulcus tangent line of the humeral head. Minimally invasive surgeries can be performed by using these palpable landmarks. The torsional deformities can be reduced with the proper angle adjustment without the need for fluoroscopy. It can also be used to treat unstable comminuted humeral fractures.

LEVEL OF EVIDENCE

Retrospective Study, Diagnostic study, Level III.

The fragility of findings of randomized controlled trials in shoulder and elbow surgery

BACKGROUND

Considered the gold standard of study designs, randomized controlled trials' (RCTs) results shape clinical practice, effect policy, and influence reimbursement. The fragility index (FI) can be used to quantitate the relative robustness of RCT results, with higher scores indicating more stout results. Unfortunately, most RCTs in surgery have fragile results. The aim of this study was to report on the FI in addition to a qualitative assessment of recent RCTs within the field of shoulder and elbow surgery.

METHODS

A systematic review was performed identifying recently published shoulder/elbow RCTs that included 1:1 allocated parallel study arms, dichotomous primary outcome variables, and statistical significance. The FI was calculated by sequentially modifying outcome groups by exchanging a nonevent in one group to an event until the P value for the outcome comparison, as calculated by the Fisher exact test, was increased above the .05 threshold.

RESULTS

Thirty RCTs were included. The median FI was 4. Sixty percent trials had a FI of 2 or less. Fifty-three percent studies reported that participants were lost to follow-up. In 87.5% of these studies, the losses to follow-up exceeded their respective FIs. Only 53% of studies defined a primary outcome variable and 60% studies performed a prestudy power analysis.

CONCLUSIONS

The median FI reported in the recent shoulder/elbow literature is 4; however, a high proportion of included RCTs display significant methodological concerns. The FI is a useful adjunct to analyze RCT results, but careful analysis of trial methods should be employed in each circumstance before drawing conclusions.

Antegrade intramedullary nail versus plate fixation in the treatment of humeral shaft fractures: An update meta-analysis

BACKGROUND

There is no consensus regarding the surgical treatment of humeral shaft fracture. The present meta-analysis was performed to compare the efficacy and safety between antegrade intramedullary nailing (IMN) and plating for humeral shaft fracture.

METHODS

PubMed, MEDLINE, Cochrane Library, EMBASE, Clinical Trails, Ovid, ISI Web of Science, and Chinese databases including WanFang Data, China National Knowledge Infrastructure were searched through March 10, 2019. The Review Manager software was adapted to perform statistical analysis and relative risk (RR) were used for the binary variables, and weighted mean difference and standardized mean difference (SMD) were used to measure the continuous variables. Each variable included its 95% confidence interval (CI).

RESULTS

A total of 15 trials with 839 patients were included in the analysis. There was significant difference between IMN group and plate group in blood loss (SMD = 3.49, 95% CI: 1.19, 5.79, P = .003) and postoperative infections (RR = 3.04, 95% CI: 1.49, 6.24, P = .002). Additionally, significant difference was observed between minimally invasive plate osteosynthesis (MIPO) group and IMN group in nonunion rate (RR = 3.20, 95% CI: 0.12, 0.84, P = .02). Statistical significance was also observed between the open reduction plate fixation group and IMN group in restriction of shoulder and elbow joints results (RR = 0.49, 95% CI: 0.26, 0.96, P < .05). No significant difference was observed for the operation time, American Shoulder and Elbow Surgeons score, nerve injury, delayed union, reoperation in either group.

CONCLUSION

IMN may be superior to plate in reducing blood loss and postoperative infections for the treatment of humeral shaft fracture. However, MIPO was superior to IMN group in nonunion and equal to IMN in other parameters. Further research is required and future studies should include analysis of assessments at different stages and follow-up after removal of the implants.

Cerclage wiring and intramedullary nailing, a helpful and safe option specially in proximal fractures. A multicentric study

PURPOSE

Antegrade intramedullary nailing is an alternative for humeral shaft fracture treatment. This surgical technique can be especially demanding in some fracture patterns, leading to problems like malunion and non-union. The purpose of our study is to demonstrate that the use of a nail with cerclage wires could be a safe procedure that facilitate reduction, specially in fractures with abduction of the proximal fragment.

MATERIALS AND METHODS

Fifty-six patients were included, from January 2007 to March 2016. In this cohort forty-two patients were females and eighteen males; mean age was sixty-seven (32-89). The fractures were reduced using a cerclage wire through a small lateral or anterior approach, then, antegrade intramedullary nailing was performed. Fracture healing was established by clinical and radiographic evaluation. Shoulder function was assessed using the Constant Score.

RESULTS

Fifty-three patients healed (94.6%) adequately. Two patients developed a non-union (3.5%). One patient developed an infection (1.8%). Transient radial nerve palsy was observed in two patients (3.5%). The mean Constant Score at the end of the study was 70 points (range from 34 to 98 points).

CONCLUSIONS

Surgical treatment of humeral shaft fractures with cerclage wire and intramedullary nailing is a safe technique to improve fracture reduction. The use of cerclage wires leads to better bone contact while minimizing malunions. The rate of non-union in our study is lower than the rate reported in the literature for humeral shaft fractures treated by intramedullary nailing alone.

Open reduction-internal fixation versus intramedullary nailing for humeral shaft fractures: an expected value decision analysis

BACKGROUND

Previous randomized controlled studies and meta-analyses have failed to collectively favor either open reduction-internal fixation (ORIF) or intramedullary nailing (IMN) fixation. The purpose of our investigation was to elucidate the optimal decision between ORIF and IMN for acute traumatic operative humeral shaft fractures through an expected value decision analysis.

METHODS

We performed an expected value decision analysis and sensitivity analysis to elucidate the difference between ORIF and IMN fixation for patients with acute traumatic humeral shaft fractures. We surveyed 100 consecutive, randomly selected volunteers for their outcome preferences. Outcomes included union, delayed union, major complications, minor complications, and infection. A literature review was used to establish probabilities for each of these respective outcomes. A decision tree was constructed and a fold-back analysis was performed to find an expected patient value for each treatment option.

RESULTS

The overall patient expected values for ORIF and IMN were 12.7 and 11.2, respectively. Despite artificially decreasing the rates of major complications, infection, delayed union, and nonunion each to 0% for IMN fixation (sensitivity analysis), ORIF continued to maintain a greater overall patient expected value (12.7 vs. 11.4, 11.2, 11.2, and 12.1, respectively). Only if the rate of nonunion after ORIF was increased from 6.1% to 16.8% did the overall expected outcome after ORIF equal that of IMN (11.2).

CONCLUSION

Our expected value decision analysis demonstrates that patients favor ORIF over IMN as the optimal treatment decision for an acute traumatic humeral shaft fracture.

Surgical interventions to treat humerus shaft fractures: A network meta-analysis of randomized controlled trials

BACKGROUND

There are three main surgical techniques to treat humeral shaft fractures: open reduction and plate fixation (ORPF), intramedullary nail (IMN) fixation, and minimally invasive percutaneous osteosynthesis (MIPO). We performed a network meta-analysis to compare three surgical procedures, including ORPF, IMN fixation, and MIPO, to provide the optimum treatment for humerus shaft fractures.

METHODS

MEDLINE, EMBASE, Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, and Cochrane library were researched for reports published up to May 2016. We only included randomized controlled trials (RCTs) comparing two or more of the three surgical procedures, including the ORPF, IMN, and MIPO techniques, for humeral shaft fractures in adults. The methodological quality was evaluated based on the Cochrane risk of bias tool. We used WinBUGS1.4 to conduct this Bayesian network meta-analysis. We used the odd ratios (ORs) with 95% confidence intervals (CIs) to calculate the dichotomous outcomes and analyzed the percentages of the surface under the cumulative ranking curve.

RESULTS

Seventeen eligible publications reporting 16 RCTs were included in this study. Eight hundred and thirty-two participants were randomized to receive one of three surgical procedures. The results showed that shoulder impingement occurred more commonly in the IMN group than with either ORPF (OR, 0.13; 95% CI, 0.03-0.37) or MIPO fixation (OR, 0.08; 95% CI, 0.00-0.69). Iatrogenic radial nerve injury occurred more commonly in the ORPF group than in the MIPO group (OR, 11.09; 95% CI, 1.80-124.20). There were no significant differences among the three procedures in nonunion, delayed union, and infection.

CONCLUSION

Compared with IMN and ORPF, MIPO technique is the preferred treatment method for humeral shaft fractures.

Reliability, validity, responsiveness, and minimal important change of the Disabilities of the Arm, Shoulder and Hand and Constant-Murley scores in patients with a humeral shaft fracture

BACKGROUND

The Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley scores are commonly used instruments. The DASH is patient-reported, and the Constant-Murley combines a clinician-reported and a patient-reported part. For patients with a humeral shaft fracture, their validity, reliability, responsiveness, and minimal important change (MIC) have not been published. This study evaluated the measurement properties of these instruments in patients who sustained a humeral shaft fracture.

METHODS

The DASH and Constant-Murley instruments were completed 5 times until 1 year after trauma. Pain score, Short Form 36, and EuroQol-5D were completed for comparison. Internal consistency was determined by the Cronbach α. Construct and longitudinal validity were evaluated by assessing hypotheses about expected Spearman rank correlations in scores and change scores, respectively, between patient-reported outcome measures (sub)scales. The smallest detectable change (SDC) was calculated. The MIC was determined using an anchor-based approach. The presence of floor and ceiling effects was determined.

RESULTS

A total of 140 patients were included. Internal consistency was sufficient for DASH (Cronbach α = 0.96) but was insufficient for Constant-Murley (α = 0.61). Construct and longitudinal validity were sufficient for both patient-reported outcome measures (>75% of correlations hypothesized correctly). The MIC and SDC were 6.7 (95% confidence interval, 5.0-15.8) and 19.0 (standard error of measurement, 6.9), respectively, for DASH and 6.1 (95% CI -6.8 to 17.4) and 17.7 (standard error of measurement, 6.4), respectively, for Constant-Murley.

CONCLUSIONS

The DASH and Constant-Murley are valid instruments for evaluating outcome in patients with a humeral shaft fracture. Reliability was only shown for the DASH, making this the preferred instrument. The observed MIC and SDC values provide a basis for sample size calculations for future research.

A Bayesian network meta-analysis of three different surgical procedures for the treatment of humeral shaft fractures

BACKGROUND

The optimal surgical procedure for humeral shaft fractures remains a matter of debate. We aimed to establish the optimum procedure by performing a Bayesian network meta-analysis.

METHODS

PubMed, EMBASE, the Cochrane Library, and Medline were searched for both randomized controlled trials and prospective studies of surgical treatment for humeral shaft fractures. The quality of the included studies was assessed according to the Cochrane Collaboration's "Risk of bias".

RESULTS

Seventeen RCTs or prospective studies were included in the meta-analysis. The pooled results showed that the occurrence rate of radial nerve injury was lowest for minimally invasive plate osteosynthesis (MIPO; SUCRA probability, 95.1%), followed by open reduction and plate osteosynthesis (ORPO; SUCRA probability, 29.5%), and was highest for intramedullary nailing (IMN; SUCRA probability, 25.4%). The aggregated results of pairwise meta-analysis showed no significant difference in radial nerve injury rate when comparing ORPO versus IMN (OR, 1.92; 95% CI, 0.96 to 3.86), ORPO versus MIPO (OR, 3.38; 95% CI, 0.80 to 14.31), or IMN versus MIPO (OR, 3.19; 95% CI, 0.48 to 21.28). Regarding the nonunion, SUCRA probabilities were 90.5%, 40.2%, and 19.3% for MIPO, ORPO, and IMN, respectively. The aggregated results of a pairwise meta-analysis also showed no significant difference for ORPO versus IMN (OR, 0.83; 95% CI, 0.41 to 1.69), ORPO versus MIPO (OR, 2.42; 95% CI, 0.45 to 12.95), or IMN versus MIPO (OR, 2.49; 95% CI, 0.35 to 17.64).

CONCLUSION

The current evidence indicates that MIPO is the optimum choice in the treatment of humeral shaft fractures and that ORPO is superior to IMN.

The inflatable intramedullary nail for humeral shaft fractures

BACKGROUND

We assessed the results of humeral shaft fracture fixation using the inflatable intramedullary nail using radiological and clinical findings.

METHODS

From 2012 to 2015, we treated 14 patients with humeral shaft fractures using inflatable intramedullary nail after closed reduction.

RESULTS

The mean follow-up time was 14.1 months. The mean time to bone union was 4.5 months. None of the patients had major perioperative mechanical complications or postoperative complications, except for the occurrence of fixation loss and non-union in one patient.

CONCLUSION

Inflatable intramedullary nails seem to be applicable, safe and effective for humeral AO/OTA type A midshaft fractures.

Causes of Secondary Radial Nerve Palsy and Results of Treatment

Background

The aim of this study was to analyze the causes that lead to secondary damage of the radial nerve and to discuss the results of reconstructive treatment.

Material/Methods

The study group consisted of 33 patients treated for radial nerve palsy after humeral fractures. Patients were diagnosed based on clinical examinations, ultrasonography, electromyography, or nerve conduction velocity. During each operation, the location and type of nerve damage were analyzed. During the reconstructive treatment, neurolysis, direct neurorrhaphy, or reconstruction with a sural nerve graft was used. The outcomes were evaluated using the Medical Research Council (MRC) scales and the quick DASH score.

Results

Secondary radial nerve palsy occurs after open reduction and internal fixation (ORIF) by plate, as well as by closed reduction and internal fixation (CRIF) by nail. In the case of ORIF, it most often occurs when the lateral approach is used, as in the case of CRIF with an insertion interlocking screws. The results of the surgical treatment were statistically significant and depended on the time between nerve injury and revision (reconstruction) surgery, type of damage to the radial nerve, surgery treatment, and type of fixation. Treatment results were not statistically significant, depending on the type of fracture or location of the nerve injury.

Conclusions

The potential risk of radial nerve neurotmesis justifies an operative intervention to treat neurological complications after a humeral fracture. Adequate surgical treatment in many of these cases allows for functional recovery of the radial nerve.

Is minimally invasive plating osteosynthesis for humeral shaft fracture advantageous compared with the conventional open technique?

BACKGROUND

The minimally invasive plate osteosynthesis (MIPO) technique has been described and used effectively in humeral shaft fractures. However, the postoperative deformity resulting from malreduction with the minimally invasive technique has not received adequate attention. The purpose of this study was to evaluate the postoperative malrotation and the functional results of the MIPO technique and conventional plating in open reduction and internal fixation after humeral shaft fracture.

METHODS

A prospective cohort research was performed; 53 cases of humeral shaft fractures in a level I trauma center were included and allocated into group I for open reduction and internal fixation or group II for MIPO. Computed tomography was used to measure the postoperative malrotation. The status of the union, functional scoring, and muscle strength were recorded at 12 months after surgery.

RESULTS

Both groups exhibited satisfactory union results and final shoulder function scoring. Shoulder girdle musculature of both groups exhibited considerable strength loss with no obvious intergroup discrepancy, with greater internal rotation strength loss compared with external rotation. A significantly increased incidence of postoperative malrotation >20° was observed in the MIPO group (40.9% vs. 0%; P < .01). A linear correlation between postoperative malrotation and range of rotation loss was observed.

CONCLUSIONS

The MIPO technique might be advantageous as a cosmetic consideration; however, it did not improve postoperative function and strength restoration results more than the open technique. Moreover, MIPO was associated with greater postoperative malrotation, which was considered to be correlated with subsequent long-term shoulder degeneration.

Management of Humeral Shaft Fractures With Intramedullary Interlocking Nail Versus Locking Compression Plate

Surgical fixation of humeral shaft fractures generally involves plating or nailing. It is unclear whether one method is more effective than the other. The aim of this study was to compare the results of the intramedullary nail and locking compression plate for the treatment of humeral shaft fractures. A total of 60 patients with humeral shaft fractures were randomized to undergo surgery with an intramedullary interlocking nail (n=30) or locking compression plate (n=30). The outcome was assessed in terms of intraoperative blood loss, operative time, hospital stay, union time, union rate, functional outcome, and incidence of complications. Functional outcome was assessed using the Constant score and the American Shoulder and Elbow Surgeons (ASES) score. Intraoperative blood loss, operative time, and hospital stay in group A (intramedullary interlocking nail) were significantly lower than those in group B (locking compression plate). No statistically significant difference was found regarding the union rate, mean Constant score, and mean ASES score between the groups. The average union time was found to be significantly lower for the intramedullary interlocking nail compared with the locking compression plate. The incidence of complications such as radial nerve palsy was found to be higher with the locking compression plate compared with the intramedullary interlocking nail. The intramedullary interlocking nail can be considered a better surgical option for the management of humeral shaft fractures because it offers decreased intraoperative blood loss; shorter operative times, hospital stays, and union times; and a lower incidence of serious complications such as radial nerve palsy.

Intramedullary nail versus plate fixation for humeral shaft fractures: a systematic review of overlapping meta-analyses

Multiple meta-analyses have been published to compare intramedullary nail and plate for treating humeral shaft fractures; however, results are discordant.The purposes of current study were to perform a systematic review of overlapping meta-analyses comparing intramedullary nail and plate fixation for the treatment of humeral shaft fractures, to appraise the methodological quality and the quality of reporting of meta-analyses, and to propose a guide through the currently discordant available evidence.This systematic review was performed according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analysis. The literature was systematically reviewed to identify meta-analyses comparing intramedullary nail and plate fixation for the treatment of humeral shaft fractures. Only meta-analyses exclusively including randomized clinical trials (RCTs) met eligibility criteria in this systematic review. Methodological quality for each included study was assessed using the Oxford Levels of Evidence and the Assessment of Multiple Systematic Reviews Instrument. We extracted all variables from the included studies and listed the results reported by them. Heterogeneity information of each variable was extracted for the included studies. An I of <60% is accepted in this systematic review. The Jadad algorithm was then applied to determine which meta-analyses provided the best evidence.Seven studies met the inclusion criteria in this study. All studies included RCTs or quasi-RCT and were Level II of evidence. Assessment of Multiple Systematic Reviews scores varied from 6 to 10 with a median of 7.86. Heterogeneity of each outcome was acceptable in those meta-analyses pooled results. The Jadad algorithm suggested that the meta-analyses can be selected based on the search strategies and application of selection. As a result, 2 meta-analyses with more RCTs were selected in this systematic review. The best available evidence suggested that the differences between intramedullary nail and plate fixation were not significant in fracture union, radial nerve injury, and infection. But intramedullary nail significantly increased the risk of shoulder complications (shoulder impingement and restriction of shoulder movement) and reoperation.We concluded that plate fixation is superior to intramedullary nail for the treatment of humeral shaft fractures.

Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures: a meta-analysis of RCTs and nonrandomized studies

PURPOSE

There is no consensus regarding treatment of humeral shaft fracture. In this meta-analysis, we pooled studies to compare dynamic compression plate with locked intramedullary nail for this injury.

METHODS

PubMed, MEDLINE, and Embase databases were searched for relevant studies published between January 1995 and July 2012. Evaluated endpoints were method-related complications and revision. Study quality was assessed, and meta-analyses were analyzed using the Cochrane Collaboration's REVMAN 5.0 software.

RESULTS

Fourteen randomized controlled (RCTs) and nonrandomized studies with 727 patients were analyzed. There was a significantly higher risk of total method-related complications and shoulder impairment resulting from locked intramedullary nailing compared with dynamic compression plating. Plating was significantly associated with a higher risk of infection and postoperative nerve palsy. There was no significant difference with respect to nonunion and revision rate.

CONCLUSIONS

Nailing may cause more method-related complications and shoulder impartment than plating, although it may lead to a lower risk of infection and postoperative nerve palsy. In the future, more high-quality RCTs are required to enhance these conclusions.

Complications after interlocking intramedullary nailing of humeral shaft fractures

INTRODUCTION

IM nails have gained popularity for stabilization of humeral shaft fractures (HSF). The initial enthusiasm was tempered by a number of specific complications and thus indications need to be re-evaluated.

PATIENTS AND METHODS

This retrospective study includes 111 patients with HSF subjected to a treatment protocol of IM fixation with first and second generation of humeral nails. Antegrade approach was used in 105 (94.5%) and retrograde in 6 (5.5%) patients. Reaming was performed in 51 (45.9%) fractures. The study covers a period of 10 years. Mean follow-up time was 3.5 (1-6) years. This investigation is directed at technical errors and complications, especially those corrected by secondary surgery.

RESULTS

We registered 52 (46.85%) intra-operative complications in 40 (36.04%) patients, on average 1.3 per patient. The most common were: distraction n=5 (4.5%), long proximal locking screws n=9 (8.1%), additional diaphyseal fracture n=7 (6.3%) and countersinking of the nail in the humeral head n=8 (7.2%). The number of postoperative complications was 40 (36.0%) related to 19 (17.1%) patients. Technical errors, such as distraction, longer nail and additional fractures have affected time to union and resulted in chronic shoulder pain. 36 (32.5%) secondary surgeries were needed to address these problems. When first generation nails are used, the intra-operative complication related risk increases 1.58 times, and the postoperative complication related risk is 1.67 times higher compared to second generation nails. According to Constant-Murley score excellent and very good functional results were achieved in 93 (83.78%) patients. While reaming did not influence the clinical results for both nail generations, overall better results were achieved with second generation nails. Postoperative shoulder pain has been registered in 18 (16.2%) patients.

CONCLUSION

We registered a number of technical errors and complications, which we consider technique specific. The analysis and avoidance of these complications, related only to IM nailing of the humerus, will allow IM nails to successfully bridge the gap between functional bracing and plating.

Intramedullary nail versus dynamic compression plate fixation in treating humeral shaft fractures: grading the evidence through a meta-analysis

There is a debate regarding the choice of operative intervention in humeral shaft fractures that require surgical intervention. The choices for operative interventions include intramedullary nailing (IMN) and dynamic compression plate (DCP). This meta-analysis was performed to compare fracture union, functional outcomes, and complication rates in patients treated with IMN or DCP for humeral shaft fractures and to develop GRADE (Grading of Recommendations, Assessment, Development, and Evaluation)-based recommendations for using the procedures to treat humeral shaft fractures. A systematic search of all the studies published through December 2012 was conducted using the Medline, Embase, Sciencedirect, OVID and Cochrane Central databases. The randomized controlled trials (RCTs) and quasi-RCTs that compared IMN with DCP in treating adult patients with humeral shaft fractures and provided data regarding the safety and clinical effects were identified. The demographic characteristics, adverse events and clinical outcomes were manually extracted from all of the selected studies. Ten studies that included a total of 448 patients met the inclusion criteria. The results of a meta-analysis indicated that both IMN and DCP can achieve similar fracture union with a similar incidence of radial nerve injury and infection. IMN was associated with an increased risk of shoulder impingement, more restriction of shoulder movement, an increased risk of intraoperative fracture comminution, a higher incidence of implant failure, and an increased risk of re-operation. The overall GRADE system evidence quality was very low, which reduces our confidence in the recommendations of this system. DCP may be superior to IMN in the treatment of humeral shaft fractures. Because of the low quality evidence currently available, high-quality RCTs are required.

Meta-analysis of the outcomes of intramedullary nailing and plate fixation of humeral shaft fractures

OBJECTIVE

The purpose of this study is to compare the outcomes of intramedullary nailing and plate fixation in the treatment of humeral shaft fractures using meta-analysis.

METHODS

PubMed, MEDLINE, EMBASE, the Cochrane Controlled Clinical Trials Register (CCTR) databases were searched for studies that investigated the efficacy of intramedullary nailing and plate fixation in the management of humeral shaft fractures. Delayed healing rate, nonunion, postoperative infection and radial nerve paralysis were key outcomes of interest. Data were searched within the time period of July 1990 through September 2012. The statistical software RevMan 5.0 was used to analyze the statistical significance of the results.

RESULTS

Total 459 cases of patients in 10 literature, including 231 cases of plate group and 228 cases of the intramedullary nailing groups were collected. The results of meta-analysis showed that delayed healing rate of humeral shaft fractures was lower in plate fixation compared with intramedullary nailing (RR = 2.64, 95% CI (1.08, 6.49), P < 0.05). No statistically significant difference in nonunion, postoperative infections, radial nerve paralysis and other complications was identified between nailing and plate fixation groups (P > 0.05).

CONCLUSIONS

In general, the effect size of intramedullary nailing may be comparable to that of plate fixation in the terms of nonunion, postoperative infections, radial nerve paralysis. The only slightly difference was identified in the event of delayed healing rate.

The function and muscle strength recovery of shoulder after humeral diaphysis fracture following plating and intramedullary nailing

OBJECTIVE

To evaluate the shoulder function and shoulder girdle muscle strength of humeral diaphysis fractures postoperatively following intramedullary nailing (IMN) and open reduction internal fixation (ORIF).

METHODS

Fifty cases of humeral diaphysis fractures were randomly allocated into two groups. Antegrade IMN and ORIF were, respectively, performed in group I and II. Union status, functional scoring, range of motion, muscle strength of shoulder girdle including external/internal rotation and abduction/adduction strength were recorded at 18 months after surgery. Statistical package for social sciences 13.0 was used for analysis.

RESULTS

Group I had lower functional score than group II (P < 0.05). Both groups had approximately 50 % of muscle strength loss on injured side. In group II, the internal rotation strength loss was significantly greater compared to group I (P < 0.01). The total side to side (internal plus external) range of rotation (ROR) lack and external ROR lack of involved shoulder was significantly greater in group I (P = 0.005 and 0.049). The range of abduction lack was also significantly greater in group I.

CONCLUSIONS

Both surgically treated groups had significant loss of muscle strength of shoulder girdle when measured at 18 months postoperatively. There was greater loss of rotation strength in ORIF group than the IMN group. However, IMN had lower functional scores and a decreased range of motion postoperatively. The assumption that rotator cuff damage caused by nailing leads to weaker abduction strength than plating was not supported.

Prediction of the rotational state of the humerus by comparing the contour of the contralateral bicipital groove: Method for intraoperative evaluation

BACKGROUND

Accurate reduction of rotational displacement for transverse or comminute fracture of humeral shaft fracture is difficult during operation. The purpose of this study was to evaluate the reliability of the bicipital groove as a point of reference for the prediction of the rotational state of the humerus on two dimensional images of C-arm image intensifier during operation for humeral shaft fractures.

MATERIALS AND METHODS

One hundred subjects, 62 male, 38 female, aged 22-53 years were recruited contralateral bicipital groove on the 45 degrees externally rotational standard anterior-posterior view recorded before surgery. Three observers, watched only contour of bicipital groove in monitor of C-arm image intensification with naked eye without looking at the subject and predicted rotational state of the humerus by comparing the contour of the opposite side of bicipital groove. The angle of discrepancy from real rotational position was then assessed.

RESULTS

The mean (SD), angular discrepancy between the neutral point and the predicted angle was 3.4°(±2.7°). A value within 5° was present in 72% of cases. All observations were within 15°. There was no interobserver variation (P = 0.47). The intraclass correlation coefficient (ICC) was 0.847.

CONCLUSION

Contour of the bicipital groove on simple radiograph was a useful landmark. Comparing the contour of the bicipital groove in the 45 degrees externally rotational standard view bilaterally, was an effective method for reduction of rotational displacement of the humerus.